048-45 Wyo. Code R. § 45-8

Current through April 27, 2019

Section 45-8 - Documentation Standards

(a) In addition to the requirements of Chapter 3, Provider Participation, of the Wyoming Medicaid Rules, the following provisions shall apply to the documentation of services, medical and financial records, including information regarding dates of services, diagnoses, services furnished, and claims affected by this Chapter.

(b) A provider shall complete all required documentation, including the required signatures, before or at the time the provider submits a claim.

(i) Documentation prepared or completed after the submission of a claim is prohibited. The Department shall deem the documentation to be insufficient to substantiate the claim and Medicaid funds shall be withheld or recovered.

(ii) Documentation shall not be altered in any way once billing is submitted unless the participant or legally authorized representative requests an amendment to the documentation in accordance with the patient privacy rules in the Health Insurance Portability and Accountability Act of 1996.

(c) A provider shall document services either electronically or in writing.

(d) Electronic documentation shall capture all data required by subsection (e) and include electronic signatures and automatic date stamps pursuant to Wyoming Statute § 40-21-107, and shall have automated tracking of all attempts to alter or delete information that was previously entered.

(i) Electronic records shall not be altered or deleted prior to submission of payment unless incorrect, and the purpose of the correction shall be captured in the electronic documentation system.

(ii) If anyone other than the employee who provided the service completes electronic documentation for the purpose of claims submission, the provider of the service shall separately maintain all written or electronic service documentation to support the claim.

(iii) A provider shall make a participant's electronic case file, specific to the case manager's caseload, available to a case manager in the electronic record in order to comply with the required documentation reviews and service unit utilization specified in this Chapter.

(iv) Case management monthly documentation in the Electronic Medicaid Waiver System (EMWS), or its successor, once marked as final and submitted to the Division in the web portal, meets the requirements for an electronic signature and date stamp. These records cannot be altered once the case manager bills for the service provided.

(e) For written documentation, each physical page of documentation shall include:

(i) Full legal name of participant;

(ii) Individualized plan of care start date for participant;

(iii) Name, type, and billing code of service provided;

(iv) Legible signature of each person performing a service, if initials are being used for documentation purposes.

(f) For written documentation, the following information shall be included each time a service is documented:

(i) Location of services;

(ii) Date of service, including year, month, and day;

(iii) Time services begin, and time services end, using either AM and PM or military time, and documenting per calendar day, even when services are provided over a period longer than one calendar day;

(iv) Initial or signature of person performing the service;

(v) A detailed description of services provided that:
- (A) Consist of a personalized list of tasks or activities that describe a typical day, week, or month for a participant, in which the participant and legally authorized representative has provided input;
- (B) Support recommendations from assessments by therapists, licensed medical professionals, psychologists, and other professionals in a manner that prevents the provision of unnecessary or inappropriate services and supports;
- (C) Reflect the participant's desires and goals; and
- (D) Includes specific objectives for habilitation services, support needs, and health and safety needs.

(g) Documentation for different services shall be on separate forms and shall clearly be separated by time in and out, service name, documentation of services provided, signature of staff providing services, and printed name of staff providing the service.

(h) A provider shall not bill for the provision of more than one direct service for the same participant at the same time unless the participant's approved individualized plan of care identifies the need for more than one (1) direct service to be provided at the same time.

(i) A provider staff member shall not bill for the provision of more than one direct service for different participants at the same time.

(j) A provider shall not round up total service time to the next unit, except as outlined in the Skilled Nursing section of the Comprehensive and Supports Waiver Service Index.

(k) Documentation of services shall be legible, retrieved easily upon request, complete, and unaltered. If hand written, documentation shall be completed in permanent ink.

(l) Services shall meet the service definitions outlined in the Comprehensive and Supports Waiver Service Index, and be provided pursuant to a participant's individualized plan of care.

(m) For all direct care waiver services, the participant shall be in attendance in the service in order for the provider to bill for services.

(n) The provider shall make service documentation for services rendered available to the case manager each month by the tenth (10th) business day of the month following the date that the services were rendered. If services are not delivered during a month, the provider shall report the zero units used to the case manager by the tenth (10th) business day of the following month.

(i) Failure to make documentation available by the tenth (10th) business day of the month may result in a corrective action plan or sanctioning.

(ii) The case manager shall give written notification of noncompliance to the provider with a copy submitted to the Behavioral Health Division. Chronic failure to make documentation available may result in provider sanctions.

(o) The provider shall make unit billing information for services rendered available to the case manager by the tenth (10^th) business day of the month after unit billing has been submitted for payment.

048-45 Wyo. Code R. § 45-8

Amended, Eff. 6/21/2017.

Amended, Eff. 7/26/2018.